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A Claude agent for insurance claims

The agent opens the file, checks the documents, tests the claim against the policy’s cover and prepares a proposal. The claims handler decides on settlement.

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Definition

A Claude agent for insurance claims is an AI system that handles a claim notification: it checks the documents received, prepares requests for the missing ones, tests the declared facts against the policy’s cover and exclusions, then drafts a summary for the claims handler. It operates in the orange zone: no settlement and no denial goes out without a human decision.

How it works

Before / after the agent

01
First notice of loss
BeforeThe claim arrives by form, email or phone, and the handler rebuilds the file by hand.
With the agentThe agent opens the file, sorts the documents received and lists the ones still missing.
02
Document checks
BeforeMissing documents are chased late and the file sits idle.
With the agentThe agent prepares the follow-up requests and checks that the documents received are consistent with the claim.
03
Coverage analysis
BeforeThe handler rereads the policy to find out whether the loss is covered, and within which limits.
With the agentThe agent tests the claim against the policy’s cover, deductibles and exclusions, citing every clause it relies on.
04
Proposal and decision
BeforeSimple and complex claims wait in the same queue.
With the agentThe agent prepares a reasoned proposal and flags atypical files. The handler decides, and the loss adjuster steps in when the file warrants it.
LOOP™ governance

Recommended trust zone

Orange zoneSupervision

A claim leads to a settlement, sometimes a denial, that directly affects the policyholder. The agent handles the file and proposes, the claims handler validates. A coverage denial or a fraud suspicion moves to the red zone: the agent stops and hands over, and never labels a case as fraud itself.

Related demo

See the agent in action

Insurance Claims Agent
Claims processed and suspicious files flagged, while the adjuster decides.
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Document Intelligence Suite
Key obligations and data extracted from your documents, with their source.
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Related resources

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Operations function
All the AI use cases for operations, from claims handling to the supply chain.
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Claude Ops
The industrialisation programme that puts this agent, and others, into production on your business processes.
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Frequently asked questions

Frequently asked questions

Can an AI agent settle a claim without human involvement?
We advise against it, especially at the start. The GDPR (article 22) restricts decisions based solely on automated processing that significantly affect a person: where such decisions are allowed, the policyholder can notably obtain human intervention and contest the decision. The agent handles the file and proposes, the claims handler decides.
Is claims handling a high-risk use under the EU AI Act?
Not as such. For insurance, Annex III of the AI Act covers risk assessment and pricing for natural persons in life and health insurance; claims handling is not listed. The GDPR still applies, as does, where the agent interacts directly with policyholders, the duty to tell them they are dealing with an AI (article 50, applicable since 2 August 2026).
How does the agent handle suspected fraud?
It spots signals (repeated claims, inconsistent documents, an unlikely timeline) and explains why a file deserves a second look. It never labels a case as fraud: the file goes to the dedicated team, red zone.
Is policyholders’ health data involved?
Yes, as soon as a claim involves health or bodily injury. Health data is a special category under article 9 of the GDPR: hosting, the agent’s access rights and data retention are set during scoping, with your DPO.
Does the agent integrate with our claims system?
Yes. It connects to your claims management system, document management and policy repositories through their APIs or MCP connectors. Using an external provider may fall under the Solvency II outsourcing rules and, for ICT services, under DORA: the insurer remains fully responsible.
Next step

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